Iowa Announces Resolution Of Medical Fee Disputes Proceedure


Des Moines. IA (CompNewsNetwork) - Over the past several months the Iowa Workers' Compensation Commission has received numerous inquires regarding the resolution of medical fee disputes.  As required by Iowa Code section 85.27(3), and rules 876 IAC 10.3 and 876 IAC 4.46, insurers and providers who have a medical fee dispute must take the following steps to resolve the dispute:

1.     An insurer who disputes a charge must give a provider written notice of the disputed charge within 60 days of receiving a bill.  Charges not in dispute must be paid to the provider before using the procedures in rule 876 IAC 10.3.

2.    The notice should contain: names of employee and employer; date of injury; date of disputed treatment; the amount of the charge the insurer agrees to pay; the amount of the charge in dispute; the reason the charge is believed to be excessive or unnecessary, and the documentation relied on; the address for directing correspondence; and the procedures available through the Workers' Compensation Commission to resolve the dispute.

3.    If the provider does not accept the amount the insurer agrees to pay, the provider must give written notice, and ask the disputed amount go to a reviewer for review. 

4.    The person chosen as the reviewer cannot be the Workers' Compensation Commission. If the parties cannot agree upon a reviewer, each shall submit a name to the commissioner, and the commissioner shall decide who is to act as a reviewer.

5.    The reviewer, as soon as practicable, is to determine in writing the amount of the charge that is reasonable and necessary.  Costs of the review are to be paid as agreed to by the parties.

6.    A dispute over a charge can include the reasonableness of the charges.  It may also include the necessity of the charge.

7.    A contested case proceeding may be commenced only after these steps for dispute resolution have been followed, and good faith efforts to resolve the dispute have failed.  Such a proceeding must be commenced within 30 days after written determination is made by the reviewer.

8.    Rule 876 IAC 10.3 does not prevent providers and insurers from developing other procedures to informally resolve their disputes, if those procedures aid in the resolution of a medical fee dispute.

If the process, detailed in rule 876 IAC 10.3, does not resolve the dispute and the parties have attempted resolution in good faith, a contest case may be initiated, pursuant to rule 876 IAC 4.46.  The following applies to contested cases regarding medical fee disputes:

1.   Evidence is filed at the time the contested case is initiated and is limited to that provided by the reviewer, and the determination made by the reviewer. 

2.   The commissioner may request or allow additional evidence.

3.    If a brief is to be filed, it needs to be filed at the time the matter is commenced.

4.    The opposing party has 30 days from the date of service of the petition, to file a response and optionally a brief.  (8-4-08)

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